Application & Checklist for Hospital Main Campus & Offsite Campus Designation Change
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Instructions for Completing the Application & Checklist for Hospital Main Campus & Offsite Campus Designation Change

  1. Please use this form when submitting information to designate an offsite campus as the new main campus of the hospital and to designate the previous main campus as a new offsite campus. Please keep in mind that an offsite campus’s licensed beds can’t exceed the number of licensed beds at the main campus.
  2. Please don’t use this form for Critical Access Hospitals. Use form HSS-HO-53b instead of this one for Critical Access Hospitals.
  3. Please fill out all hospital information.
  4. Please identify a designated contact person of the hospital for all information to be communicated through.
  5. Please list the hospital’s DBA name.
  6. Please complete the checklist in its entirety.
  7. Please place all attachments behind this checklist in the order listed on the checklist.
  8. This form is to be used when there are no changes other than the designation of the main campus as an offsite campus and the offsite campus as the main campus. Do NOT use this packet if you are making any changes to the floor plan, beds, services, ownership, etc.
  9. Please submit the hospital packet in its entirety with this checklist on top of all documents.

All packets will be reviewed by the administrative assistant. If the packet is determined to be incomplete, the entire packet will be sent back to the facility for completion. Once a packet is determined to be complete by the administrative assistant, it will be placed in line for processing. Please keep in mind that with the large volume of work being requested by hospitals, the wait time can be lengthy. The forms, fees and information should be submitted to the state office approximately 6 to 8 weeks prior to your anticipated opening date.

The Department of Health and Hospitals shall not process any application until all forms, required applicable accompanying information and fees are received.

Payment Information
Check or Money Order Number:
Mail Payment & Payment Transmittal Form To / Mail License Application To
DHH Licensing Fee
PO Box 62949
New Orleans, LA 70162-2949 / Department of Health & Hospitals
Health Standards Section
P.O. Box 3767
Baton Rouge, LA 70821-3767
Application Date:
Administrator: / Designated Contact Person:
Administrator Phone Number: / Contact Person Phone:
Administrator Email: / Contact Person Email:
Main Campus
Location of the Main Campus prior to this action:
Location of the Main Campus after this action:
Is the new main campus within 35 miles of all of the offsite campuses? Yes No Explain:
Will the DBA Name change with this action: No Yes (if Yes, please write the name exactly as it will appear on the license and the IRS documentation)
Main Campus Building Description:
  • Name and Geographical Address for each building being licensed on the main campus (please identify which one is the main hospital building):
  • Multi-story or single story (explain for each building):
  • Owned or Leased (explain for each building):
  • Sole occupant or are other tenants in the building (explain for each building):
  • Any other businesses on the campus (explain):
  • Co-located with other health care providers (explain for each building):
  • If you don’t occupy the entire building what floor are you on? (explain for each building):
  • Are there other businesses on the same floor as your hospital? (explain for each building):
  • Type of Services Offered:
  • Are there any PPS-excluded psych units, PPS-excluded rehab units, or SNF units at this location? Yes No Explain:
  • Number of Beds: Please note that you can’t change anything about the beds with this application.

Offsite Campus
Location of the Offsite Campus prior to this action:
Location of the Offsite Campus after this action:
Will the DBA Name change with this action: No Yes (if Yes, please write the name exactly as it will appear on the license and the IRS documentation)
Building Description:
  • Name & Geographical Address for each building being licensed (please identify which one is the main offsite campus building):
  • Multi-story or single story (explain for each building):
  • Owned or Leased (explain for each building):
  • Sole occupant or are other tenants in the building (explain for each building):
  • Any other businesses on the campus (explain):
  • Co-located with other health care providers (explain for each building):
  • If you don’t occupy the entire building what floor are you on? (explain for each building):
  • Are there other businesses on the same floor as your hospital? (explain for each building):
  • Type of Services Offered:
  • Are there any PPS-excluded psych units, PPS-excluded rehab units, or SNF units at this location? Yes No Explain:
  • Number of Beds:Please note that you can’t change anything about the beds with this application.

Criteria (Each of these must be attached in order for your application to be processed): / Yes / No / Describe
HSS-HO-053 Application & Checklist for Hospital Main Campus & Offsite Campus Designation Change / Attach
New Main Campus
HSS-HO-016a & HSS-HO-016b Worksheet for Hospital Beds & Rooms for the new main campus / Attach
Current Office of State Fire Marshal Inspection Approval for all buildings licensed for the new main campus. / Attach
Current Office of Public Health Inspection Approval for all buildings licensed for the new main campus. / Attach
Current Office of Public Health Kitchen/Retail Food Inspection for the new main campus / Attach
HSS-HO-09 Attestation for a Licensed Hospital (for the new main campus) / Attach
HSS-HO-21 Notification of Co-Located Status for the new main campus / Attach
Site Map showing where all buildings are located on the new main campus relative to other buildings, parking and streets. Please demarcate & name the buildings that you are licensing on the new main campus. / Attach
11 x 17 copy of the architecturally scaled floor plans for each floor of each building that you want licensed with dimensions and identification of service areas (i.e. nurse’s station, dining area, patient room numbers, etc.). / Attach
Letter on hospital letterhead stating that either the hospital owns the space for all buildings on the new main campus and they are not leased/subleased to anyone or that the hospital is the owner of the space through a lease/sublease. / Attach
Submit documentation (maps) showing that the new main campus is within 35 miles of each of its offsite campuses. / Attach
New Offsite Campus
HSS-HO-016a & HSS-HO-016b Worksheet for Hospital Beds & Rooms for the new offsite campus / Attach
HSS-HO-08 Questionnaire for a Hospital’s Offsite Campus for the new offsite campus / Attach
HSS-HO-06 Worksheet for a Remote Location for the new offsite campus / Attach
Current Office of State Fire Marshal Inspection Approval for all buildings licensed for the new offsite campus. / Attach
Current Office of Public Health Inspection Approval for all buildings licensed for the new offsite campus. / Attach
Current Office of Public Health Kitchen/Retail Food Inspection for the new offsite campus / Attach
HSS-HO-009 Attestation for a Licensed Hospital (form the new offsite campus) / Attach
HSS-HO-21 Notification of Co-Located Status for the new offsite campus / Attach
Site Map showing where all buildings are located on the new offsite campus relative to other buildings, parking and streets. Please demarcate & name the buildings that you are licensing on the new offsite campus. / Attach
11 x 17 copy of the architecturally scaled floor plans for each floor of each building that you want licensed with dimensions and identification of service areas (i.e. nurse’s station, dining area, patient room numbers, etc.). / Attach
Letter on hospital letterhead stating that either the hospital owns the space for all buildings on the new offsite campus and they are not leased/subleased to anyone or that the hospital is the owner of the space through a lease/sublease. / Attach
General
Copy of the payment transmittal form and check for $600 plus $300 for each offsite campus (not just the one changing) plus $5 for each inpatient room at all campuses / Attach
IRS Documentation showing the Legal Name of the hospital and the EIN / Attach
Management Agreement if applicable / Attach
Secretary of State Registration showing the new main campus address / Attach
Articles of Organization showing the approval of this action / Attach
Confirmation by letter or email from the Accrediting Organization indicating that they are aware of this change. / Attach
Complete the following if you are certified to participate in the Medicare and Medicaid Programs
Copy of the confirmation from the Medicare Administrative Coordinator (MAC) showing that they received the CMS 855A for this action. It is the responsibility of the hospital to submit the 855A to the fiscal intermediary. This will not be processed until the approved CMS 855A has been received at Health Standards. / Attach
Copy of the exact CMS 855A that was submitted to the MAC for this action / Attach
Approved CMS 855A and Summary Letter from the MAC recommending the recognition of the new main campus new offsite campus. / Attach
Attestation & Signature
I understand that if the agency license is granted, it is granted for one year and shall become void upon change of ownership or change in geographical address. It is my responsibility to notify the Department of Health and Hospitals, Bureau of Health Services Financing, Health Standards Section in writing of any changes in the information provided in this application in a separate packet. I attest that the Hospital currently complies with the requirements of the Office of State Fire Marshal and Office of Public Health. I certify that the information herein is true, correct and supportable by documentation to the best of my knowledge. Documentation of the information above is available upon request by the Department of Health and Hospitals.
Authorized Representative’s Printed Name & Title:
Authorized Representative’s Signature / Date:
For DHH Use Only / Date / Yes / No / Comments
Incomplete Packet Sent Back To Facility along with instructional letter:
Packet Ready for Program Manager Review
ACO Information Updated (facility prop, buildings, branches, notes, cert kit)
CMS 1539s Distributed
POPS updated
License & Approval Letters Distributed
CMS Notified
Logs Updated
Prepped & submitted for filing

HSS-HO-053a (05/16)